vertigo Flashcards
what does the external ear include?
pinna, external auditory meatus, tympanic membrane, wax glands and hair follicles
how much of the external ear is cartilaginous and bony
1/3 outer cartilaginous and 2/3 bony
the inner ear resides where
pertrous part of the temporal bone
what is the oval window
The stapes articulates with the oval window, causing movement of perilymph, and
a pressure change, compensated by the round window.
how many semicircular canals are there adn their names
3
anterior semicircular canal
lateral semicircular canal
posterior semicircular canal
what is perilymph
fluid that resembles CSF and the membranous labyrinth is suspended in perilymph
the role of cochlea
responsible for the perception of hearing
what area detects low and high frequency sounds
low - apex of the cochlea
high - base of the cochlea
division of the vestibular system
semicircular canals
utricle
saccule
which parts of the vestibule system detect movement
Utricle – Hair cells point Up – Detect linear/horizontal movement
Saccule – Hair cells stick out to the Side – Detect vertical movement
semicircular canals rotary movement
role of the tectorial membrane
movement of that causes movement of hair cells and subsequent depolarisation of neuronal fibres allowing perception of sound
Balance requires what elements
input from the vestibular system to be integrated centrally with proprioceptive and visual input.
what is vestibulo ocular reflex
coordinates eye movement with head movement, in order to provide clear vision during motion and maintain balance.
impaired - then when you move your head left then the eye moves right but you seen nystagmus
tests to differentiate central and peripheral vertigo
Head Impulse - saccades peripheral cause of vertigo Nystagmus Test Skew - central
causes of vestibulo ocular reflex issues
trauma
viral infections especially in elderly
importance of vestibulo ocular reflex
sports related activites
driving
walking
symptoms of vestibulo ocular reflex impairment
ovement-related dizziness, blurry vision, difficulty maintaining balance with head movements, and even nausea
what is the fovea
macula part of the retina clearest image
what parts of the body maintain balance
vestibular system
eyes
proprioception
sensation
causes of vestibular disorders
central stroke neoplasms drugs brain tumor MS - demyelination migraine cerebrovascular disease
peripheral semicircular canals utricle saccule BPPV meniere's vestibular neuronitis
define vertigo
Hallucination of rotatory movement
◦ “Room spinning”
Cardinal symptom of disease of the vestibular
system
define BPPV
Acute rotatory vertigo lasting seconds
triggered by certain head movements. Distressing for the patient and at times disabling
cause of BPPV
The underlying cause are otoliths (crystals) in the semicircular canals (most commonly posterior) causing abnormal stimulation of the hair cells giving a hallucination of movement i.e. vertigo.
How is BPPV diagnosed
Diagnosis
◦ Dix Hall-pike manoeuvre
o Diagnose Posterior Semi-circular canal if rotatory (left ear affected then itll be clockwise and right ear affected then itll be anti-clockwise), upbeating nystagmus is noted
Treatment for BPPV
Treatment
◦ Epley manoeuvre
◦ Brandt-Darrof
exercises
define positional nystagmus
when nystagmus is observed when the head position changes
Most common type of BPPV
Posterior canal BPPV
Risk factors of BPPV
ear surgery previous ear pathologies head trauma asso with sleep position prolonged recumbent positions
complications of the patient
- Falls – old people
- Difficulty performing daily activities
- Adverse effects on quality of life
- Increased likelihood of depression
presentation of BPPV patient
- Ask if it is triggered by specific movements and positions of the head relative to gravity – lying down, looking up, bending over, turning over in bed
- May modify movements to limit symptoms
- Transient episodes with head movements
- Nausea and vomiting may occur
- Light headedness and imbalance
- SURGICAL HISTORY
- PAST EAR ISSUES
HEARING IS NOT AFFECTED
TINNITIS IS NOT A FEATURE
exceptions for doing Dix Hallpike manoeuvre
If the patient has back, neck or cardiovascular problem such as carotid sinus syncope then BE CAUTION DOING DIX-HALLPIKE MANOUEVRE.
what to advice to patient with BPPV
- Most recover over several weeks without treatment however symptoms may last longer or even recur
- Simple repositioning manoeuvre can help alleviate the symptoms
- Get out of bed slowly and to avoid tasks looking upwards
- The Driver and Vehicle Licensing Agency (DVLA) states that people with ‘liability to sudden and unprovoked or unprecipitated episodes of disabling dizziness’ should stop driving and inform the DVLA.
- HOWEVER BPPV IS NOT SPONTANEOUS OR UNPROVOKED
- Workplace
o Have to inform if they use heavy machinery or ladders or drive. A vehicle - Falls in the home – how to reduce it
Management of BPPV
- Watchful waiting – see if it resolves without treatment
- If patient wants treatment
o EPLEY MANOEUVRE
BE CAUTION IF PATIENT HAS NECK OR BACK PROBLEMS, CARDIAC DISEASE, SUSPECTED VERTEBROBASILAR DISEASE, CAROTID STENOSIS OR MORBID OBESITY
Symptoms may improve shortly after treatment but full recovery may require a couple of weeks
If they do not settle after 1 week then repeat if you are confident it is BPPV
Semont manoeuvre is less common
Brandt-Daroff exercises – do at home – GOOD IF EPLEY CANNOT BE PERFOMED IMMEDIATELY OR IS INAPPROPRIATE
Return after 4 weeks if symptoms have not been resolved
When to refer a BPPV patient
- Admit the person to hospital if they have severe nausea and vomiting and are unable to tolerate oral fluids.
- (for example the Epley manoeuvre) is not available in primary care.
- Physical limitations affect the safety or practicality
- A canalith repositioning procedure (for example the Epley manoeuvre) has been performed and repeated, and symptoms are still present.
- Symptoms or signs are atypical.
- Symptoms and signs have not resolved in 4 weeks.
- There have been three or more periods during which the person has experienced episodes of vertigo
what is vestibular neuritis
acute, isolated, spontaneous, and prolonged vertigo of peripheral origin
due to inflammation of the vestibular nerve and may occur after a viral infection
HEARING IS NOT AFFECTED
Complications of vestibular neuritis
BPPV
Phobic postural vertigo, which presents with persistent dizziness and feelings of unsteadiness and fear of falling, despite lack of actual falls
Adverse effects on quality of life and independence (for example daily functioning and employment).
Increased risk of falls.
symptoms of vestibular neuritis
rotational vertigo - spontaneously, sudden, develop on waking, or may worsen over the course of the day. It is exacerbated by changes of head position, but is initially constant even when the head is still. Acute symptoms usually settle in a few days and gradual recovery occurs over 2–6 weeks.
nausea, malaise, pallor and sweating
Balance may be affected, increasing the risk of falls. People with vestibular neuritis may be unsteady and veer to the affected side.
ask about recent viral illness
signs of vestibular neuronitis
nystagmus - fine horizontal - mixed horizontal-torsional, beats in the same direction
head impulse teat may be positive
differentials of vertigo
BPPV
menieres
labyrinthitis
vestibular neuronitis
Acoustic neuroma
vertebrobasillar ischaemia
central causes - migraine stroke cerebellar tumour and MS
posterior circulation stroke
trauma
multiple sclerosis
ototoxicity e.g. gentamicin
what advise to give a pt with vestbular neuritis
symptoms will settle over several weeks
alcohol, tiredness or intercurrent illness may worsen this
bed rest necessary
do not drive if feeling dizzy or gonna get vertigo
workplace - using laders, heavy machineryor driving is not good
falls
when to refer a patient with vestibular neuronitis
Symptoms are not typical of vestibular neuronitis (for example additional neurological symptoms).
Symptoms persist without improvement for more than 1 week despite treatment (urgently refer).
Symptoms persist for longer than 6 weeks — investigation to exclude other causes, or vestibular rehabilitation may be required.
how to treat vertigo symptoms
To rapidly relieve severe nausea or vomiting associated with vertigo, consider giving buccal prochlorperazine, or an intramuscular injection of prochlorperazine or cyclizine.
To alleviate less severe nausea, vomiting, and vertigo, consider prescribing a short oral course of prochlorperazine, or an antihistamine (cinnarizine, cyclizine, or promethazine teoclate).
Advise the person to take medication regularly for up to 3 days
side effects of quininue
tinnitus, sweating, low platelets and increased sweating ototoxic
ototoxic medicines
gentamicin, quinine, furosemide, aspirin and some chemotherapy agents
smaller causes of vertigo
posterior circulation stroke
trauma
multiple sclerosis
ototoxicity e.g. gentamicin
vertigo when extending neck
vertebrobasillar ischaemia
risk factor for vertibrobasillar ischaemia
CVS disease
therosclerosis in the vertebrobasilar distribution is exacerbated by changes in head position, causing ischaemia and resultant symptoms.
viral labyrinthitis
Recent viral infection Sudden onset vertigo Nausea and vomiting Hearing may be affected tinnitus
vertebrobasillar ischaemia
Elderly patient
Dizziness on extension of neck
treatment for labyrinthitis
anithistamines upto 3 days
how to differentiate between peripheral and central causes of vertigo
head impulse test positive in peripheral causes
